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JUN-20-2a01 13�59 MINNEHAHA CREEK WATERSHED 6124710682 P.02i02 <br /> - (// ' /�'`' L v����c, <br /> CQMBINED.yOYNT NOTIFICATION�'ORM-WA�TER RESOURCE A�PLICA�'ION appl <br /> Use this form to notify/apply,to the Minnehaha Creek Watershed Districc (MCWD),their engineering cot�sultants,the <br /> DNR,an.d the H�nnepin+Conser�vation Di�trict.of a proposed water/wetland project or work which may fall within their <br /> .jurisdiction, These agencies should advise you of�their jurisdietion or pemut requiremcnes withiti 10 days.Fill out tlus <br /> form completely and mail a copy,with plan,maps,etc..,to the MCWD,Gray Freshwater CenCer,Navarre,2500 <br /> Shadywood Road,Suite 37,Excelsior, MN 55331. Keep a copy for your records.YOU MUST OBTAIN ALL <br /> REQUIRED AUTHORIZATIONS BEFORE�EGXNNING WORK_ <br /> I.Applicant's Namc(Last,First,M.i.) Pltuile No, <br /> (�'l Gra huro n w- G hr is �' � � ' <br /> Address(Street,RFD,Box �,City,State,2ip) �J. <br /> �'� l • <br /> 2_ Location of proposed project(Atrach drawing w/direc[ions to site): 5 Ce a e ✓'^e°L <br /> COCINTY QTR SECTION(s) SECTiON(s) TOWNSHIP(s) RANG�(s) Lot,Block,Subdivision <br /> PROJEC'1 ADbnESS� Fe 5 reE CiTY: � ro h p <br /> 3. L�NC;TIl OF SHORL AFF�CT�D(in feet); N• � VOLUME OF FILL OR EXCAVATION(Cubic yards): 2,� 00 �c�3• <br /> A7tEA FIT.LED QR�XCr4VATEb IS Acres,OR Square Feet. � u a 0 � �� <br /> l <br /> 4. 7YP�OF PERMrT HF(NG APPL(Ep FU1�: (Check A.11 that apply); <br /> ❑STORMWATER MANAGEMENT PLAN ❑FLOODPLAIN ALTERATION ❑WETLAN O ALTERATICIN <br /> ❑SHORELINE IlVg'ROVEMENT ❑STORM SEWER OUTFALLS ❑ EXCA'VAT[ON(DREDG[lVG) <br /> a.�1t1P1ZAP �. a.�WILDLIFE � <br /> 6.❑SANDBLANKET ❑ICE RIDGE REMOVAL b.�NAVTGA770N <br /> c.[JRETAINING WALL c.�B1�ENGTNEERTNG <br /> ❑BRIQGE&CUI.V6RT CROSSTNGS <br /> OTHER(DESCRIBE) <br /> _ ros i o u� G o r��r-d <br /> 4a. APPLICANT'S REPR�SENTA7[VE:(Licensed Lontrac[or,En�ineer,ecc.._) lnclude name,address&phone numbdr, <br /> /� le /-�u�.� �- �a�f�►�r`S, � s3Zh ���a. 8��d . (q5a) �1 �6- 5�49 <br /> S.PROJECT PURPOSE(why is this project nccdcd-what bcncfits will it providc?) <br /> � /U��.0 /�es r c��s� c � <br /> 6.ALTERNATIVES(dcscribc any other sitcs or mcthods that could bc used to achicve thc purposc of your projcct whilc avoiding or <br /> minimizing watcr/wctland impac;cs. AUach�dililional sh�ets,iFncedecl. ,, / /n • <br /> /� • I`'t". <br /> 7.DATES: Proposcd start of activiCy: ���� � Q � Proposed eompletion: (p � // � Q Z <br /> Iderttj o.a com.leted work on attached drawin ) <br /> 8. NAMES ADDRES �S OI'ADJOIN G PROP�RTY OWN�RS(Auach lisc if mor�) <br /> ���i� ���� �� �� <br /> 9. P�RMITS HAV�B��N RECEIVEb (Fd)OR APPLiED rOR(A)FROM: DNR AZtMY CORPS OF ENGR <br /> COUNTY CITY MN POLLUTION CONTROL AGENCY <br /> o �ro er �v� raG�55 <br /> I hcrcby no� thc rccipicnes oFthis fornt of che proj�ct proposcd hcr�in And request 1 be ttdvised ol any p�rmits or other dzterminations <br /> c�nccmin�this��rojccr.rh�t T m���r ohtt,;n, T imclr.r�ts�nd ihat Pmcr,cefing wirh work hr.fpre sill reqi�irr.d a»thorization��rc nhtstinr.d m�1y he <br /> subjec� �ede 1, Stat or local administracive,civil and/or cricninal penalties. <br /> s � <br /> Si nAture of Person Pro,osin P�o'ect o ent Dace <br /> TOTAL P.02 <br />